Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1 75 76 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1
PETİDİNE BAĞLI ANİ ÖLÜM
PETHIDINE RELATED SUDDEN DEATH
ÖZET
İlk sentetik opioid analjezik olan pethidine potansiyel bir anti-spazmodik ajan olarak geliştiril-miştir. Petidin orta-şiddetli ağrı tedavisinde kullanılır. Morfinden daha güvenli ve bağımlılık açı-sından daha az risk taşır. Aşırı doz, respiratuar depresyon veya komaya neden olabilir.
Sunduğumuz olgu, hastanedeki odasında ölü bulunan 34 yaşın-da bir erkek doktordu. Doktor koltukta oturuyordu ve yanın-da kullanılmış 100 mg Aldolan (petidin) ampülü ve bir enjektör bulundu. Akrabalarından alı-nan bilgiye göre birkaç yıl önce servikal disk hernisinden opere olmuştu ve operasyon sonrasın-da başağrılarınsonrasın-dan şikayetçiydi. Başağrılarından dolayı sıklıkla oral analjezik almaktaydı. Mikroskopik incelemede akci-ğer arteriol ve kapillerleri ile pulmoner arter dallarının lü-menlerinde trombuslar
mevcut-tu. Detaylı tıbbi hikaye, sistemik otopsi, histopatolojik inceleme ve toksikolojik analiz ölüm se-bebinin petidine bağlı respira-tuar arrest olduğunu ortaya çı-kardı. Bu çalışmada hastaların sağlık çalışanı dahi olsa ilaç kullanımının bir doktor gözeti-minde olması gerektiğine dikkat çekmek istedik.
Anahtar Kelimeler: petidin, ani
ölüm, solunum durması
ABSTRACT
Pethidine, the first synthetic opi-oid analgesic, was developed as a potential antispasmodic agent. Pethidine is used to treat mode-rate to severe pain. It is safer than morphine and carries less risk for addiction. Pethidine overdose can cause respiratory depression or coma.
The case we present is a 34 years old male doctor found dead in his room at the hospital. Doctor was found dead sitting on an armchair where there was a used 100 mg Aldolan (Pethidine) ampoule and an injector. According to informa-tion taken from his relatives, he had been operated for cervical disc hernia a few years ago and complaining about headaches af-ter operation. He had been frequ-ently using oral analgesic drugs because of his headaches.
In the microscopic examination, there were thrombi in the lumens of pulmonary artery branches,
arterioles and capillaries. A de-tailed medical history, a systemic autopsy, histopathological exami-nation and toxicological analysis revealed that the cause of death was the pethidine-related res-piratory arrest. In this study, we wanted to point out that drug usage in patients should be un-der supervision of a doctor even if they are health care workers.
Key words: pethidine, sudden
death, respiratory arrest
Bozdağ Z, Şamdancı ET, Şahin N, Aydın NE, Sayın S, Özcan EM Petidine Bağlı Ani Ölüm
OLGU SUNUMU CASE REPORT
1 Malatya Devlet Hastanesi Patoloji Bölümü, Malatya, Türkiye 2 İnönü Üniversitesi Tıp Fakültesi Patoloji Bölümü, Malatya, Türkiye
Sorumlu Yazar: Emine Türkmen Şamdancı
İnönü Üniversitesi Patoloji ABD Malatya - Türkiye, e-posta: turkmenmd@yahoo.com Alındı: 17.08.2012 / Kabul: 17.01.2013
Zehra Bozdağ1, Emine Türkmen Şamdancı2, Nurhan Şahin1, Nasuhi Engin Aydın2, Sadegül Sayın2 Zehra Bozdağ1, Emine Türkmen Şamdancı2, Nurhan Şahin1, Nasuhi Engin Aydın2, Sadegül Sayın2 1 Department of Pathology. Malatya State Hospital, Malatya, Turkiye
2 Department of Pathology, Medical Faculty, Inonu University, Malatya, Turkiye
Correspondence to: Emine Türkmen Şamdancı
İnönü Üniversitesi Patoloji ABD Malatya - Türkiye, e-posta: turkmenmd@yahoo.com Received: August 17, 2012 / Accepted: January 17, 2013
Kantarci NM, Baklacioglu F, Kandemir E, Ozcan EM. A dysgraphic handwriting sample of an epileptic psychosis patient: case report. J For Med 2012;26(3):203-7 doi: 10.5505/adlitip.2012.87609 Kantarci NM, Baklacioglu F, Kandemir E, Ozcan EM. A dysgraphic handwriting sample of an epileptic psychosis patient: case report.
Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1 77 78 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1
INTRODUCTION
In the treatment of moderate to severe non-cancer pain in selec-ted patients, prescribed opioid analgesics are widely accepted as a treatment option (1,2). Meperi-dine (pethiMeperi-dine), the first synthetic opioid, was developed by German chemists as an antispasmodic drug. The analgesic effects of pethidine were identified several years later in 1939 (3). Pethidine is commonly used in single dose as a preoperative medication and also in multiple doses as an anal-gesic. Correlations between plas-ma concentrations of pethidine, analgesia and side effects such as respiratory depression have been established (4).
CASE
A 34 years old male doctor was found dead in his room at the hospital. Doctor was found dead on an armchair where there was a used 100 mg Aldolan (Pethidi-ne) ampoule and injector near it. According to information taken from his relatives, he had been operated for cervical disc hernia a few years ago and complaining about headaches after operation. He had been frequently using oral analgesic drugs because of his headaches.
At autopsy there were no specific macroscopic findings in the visce-ral organs except lungs. The we-ight of lungs was increased and cut surfaces were dark brown colored and more solid. For his-tomorphologic examination, the tissue specimens obtained from
the brain, cerebellum, liver, lung, heart, kidney and pancreas were sent to the pathology laboratory of Inonu University Medical Fa-culty in 10% formalin solution. For each specimen, standard pat-hological examination was perfor-med macroscopically and micros-copically. After the routine tissue processing, the sections were stained with hematoxylin-eosin (H&E) and examined under the light microscope. Microscopically, trombi were seen in the lumens of arterioles and capillaries of the lung (Figure 1) as well as the branches of the pulmonary arteri-es (Figure 2). Minimal myocardial interstitial fibrosis was detec-ted. A detailed medical history, a systemic autopsy, histopathologi-cal examination and toxicologihistopathologi-cal analysis revealed that the cause of death was the
pethidine-rela-ted respiratory arrest.
DISCUSSION
Deaths resulting from extraor-dinary reasons, such as the fire-arm injuries, explosive injuries, penetrating stab wounds, traffic accidents, falls, occupational ac-cidents, intoxications, electrocuti-on, strike of lightening and mec-hanic asphyxia can be considered as forensic cases. Here, the most important task of the physician is, while practicing the medical aid needed to the patient, to determi-ne whether it is a forensic case or not. After deciding that it is a forensic case, physician have to notify the police forces as soon as possible (5,6).
Drug intoxications and abuses are always considered as forensic ca-ses. Drug intoxications are often
seen as suicide cases but in our case the intoxication of pethidine occurred due to the abuse of pet-hidine for its analgesic effects. In the literature, Büyük et al., repor-ted a sudden death of a health care worker related with abuse of pethidine, as our case (7).
Pethidine inhibits serotonin and noradrenaline reuptake mecha-nisms. The pethidine usage may result in the production of sero-tonin toxicity in the presence of a second medication with seroto-nergic activity. Serotonin toxicity (also known as serotonin syndro-me) is caused by the excess sero-tonin levels in the central nervous system (CNS). Selective serotonin reuptake inhibitors (SSRIs), mo-noamineoxidase inhibitors (MAO-Is) and direct stimulators of the serotonin receptors (bromocripti-ne, lithium) can cause serotonin
toxicity with the simultaneous use of pethidine (8,9). There is no ot-her drug use history in our case. Anaphylactic and true allergic reactions to opioid analgesics are rare (10). There was only one anaplactic reaction to pethidine reported between years 1975-1987 (11). Daldrup reported a case of sudden death due to acute pethidine intoxication (12). In our case, toxicology report indicated that only pethidine was present in the serum and urine. Unfortu-nately we couldn’t obtain detailed pethidine level measurement re-sults.
Opioids are widely used drugs and because of their narrow therape-utic index, they can be associated with severe toxicity. In this study, we wanted to point out that drug usage in patients should be
un-der supervision of a doctor even if they are health care workers.
Figure 1: Arterioler trombosis on the lung sections.
H&E X100
Figure 2: Trombosis of the branch of pulmonary
artery. H&E X400
Bozdağ Z, Şamdancı ET, Şahin N, Aydın NE, Sayın S, Özcan EM
Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1 79 Adli Tıp Dergisi / Journal of Forensic Medicine, Cilt / Vol.:27, Sayı / No:1
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6. Yavuz MS, Ozguner IF: Süleyman Demirel Üniversitesi Tıp Fakültesi Acil Servis’ine 1999-2001 yılları arasında müracaat eden adli olguların değerlendirilmesi. Adli Tıp Derg 2003, 17:47-53
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